H. Kaz Soong

Adverse Reactions to Virgin Silk Sutures in Cataract Surgery

During the past 3 years, 12 patients (14 eyes) were encountered with severe reactions to virgin silk sutures used in cataract surgery. These reactions included nodular episcleritis, peripheral corneal ulceration, and wound necrosis with dehiscence, sometimes resulting in endophthalmitis or epithelial downgrowth. Conjunctival and scleral histopathologic studies in four eyes showed acute and chronic inflammation with multinucleated giant cells. Successful treatment included removal of the virgin silk sutures, resuturing with 10-0 nylon sutures, securing the necrotic tissue with cyanoacrylate adhesive, and resection of the inflamed superior conjunctiva. All four patients who had bilateral cataract surgery experienced either simultaneous flare-ups of both eyes or accelerated reactions after surgery on the second eye, which suggests a possible role of prior sensitization.

Diamond burr superficial keratectomy for recurrent corneal erosions.

Aims: To evaluate the efficacy and safety of diamond burr superficial keratectomy in the treatment of recurrent corneal erosions. Methods: A retrospective review of 54 eyes (47 patients) with recurrent corneal erosions treated with diamond burr superficial keratectomy. Preoperative and postoperative visual acuities and refractions, slit lamp examination findings, and the incidence of recurrent erosion after keratectomy were studied. Specular microscopy was also performed in six patients before and after surgery. Results: 30 eyes had underlying map dot fingerprint anterior basement membrane corneal dystrophy, while 24 eyes did not. Postoperative follow up time ranged from 3 to 53 months (mean 12.3 months). Corneal erosion recurred in three eyes (6%) after diamond burr superficial keratectomy. This procedure improved the best corrected visual acuity from 20/26 to 20/22 by logMAR statistical evaluation (p=0.002) and caused very little change in the refractive spherical equivalent. No endothelial cell loss or changes in morphology were noted on specular microscopy. Conclusion: Diamond burr superficial keratectomy appears to be an effective and safe method of treating recurrent erosions and is a good alternative therapy to needle stromal micropuncture, Nd:YAG induced epithelial adhesion, and excimer laser surface ablation.

Postoperative endophthalmitis associated with sutured versus unsutured clear corneal cataract incisions

Aim: To compare the incidence of postoperative endophthalmitis in clear corneal cataract surgeries performed with and without suture closure, antibiotics and povidone iodine. Setting: Ambulatory surgery facility. Methods: In a retrospective, consecutive case-series study, we reviewed the incidence of endophthalmitis in 815 consecutive eyes that underwent cataract surgery by a single surgeon over a 5-year period (379 unsutured and 436 sutured, 294 without and 521 with antibiotic drops in the immediate postoperative period, and 247 without and 568 with povidone iodine before patching). Results: There were five cases of culture-positive postoperative endophthalmitis in the unsutured group and none in the sutured group (p = 0.022). Although patients in these two groups received routine preoperative antibiotic and povidone-iodine drops, those in whom antibiotic eye drops were not initiated until the day after surgery (p = 0.006) and those who did not receive 5% povidone-iodine drops immediately after wound closure (p = 0.031), had a higher incidence of endophthalmitis. Conclusion: Results suggest that by suturing the corneal incisions, by initiating antibiotic eye drops within the first 24 h of surgery and by instilling povidone-iodine drops after closure, the incidence of endophthalmitis after cataract surgery could possibly be reduced.

Lamellar corneal patch grafts in the management of corneal melting

Purpose. To evaluate the clinical indications and results of reconstructive (tectonic) lamellar keratoplasty in corneal melting. Methods. A nonrandomized, uncontrolled retrospective case series of 64 consecutive patients (80 eyes) who underwent lamellar keratoplasty for corneal melting at our institution over a 17-year period. We reviewed the (a) clinical indications, (b) visual acuities, (c) postoperative corneal clarity, and (d) postoperative complications. Comparisons in visual acuity were made between central and peripheral corneal melts. The statistical influence of patient age, diagnosis, and corneal graft size on pre-and postoperative visual acuity values also was studied. Results. Although reconstructive lamellar keratoplasty for active corneal melting was effective in saving the integrity of the globes in all but four patients, the postoperative visual acuity remained poor in the majority of cases because of the often devastating nature of the underlying ocular diseases. Only 14 patients had best postoperative visual acuities of 20/100 or better. Repeated lamellar keratoplasties were necessitated by corneal opacification, infection, or progressive postoperative corneal dissolution in 14 cases. Subsequent vision-restoring surgeries, consisting of penetrating keratoplasties or cataract extractions, were done in 11 eyes with modest improvement of visual acuity. Postoperative visual acuity was significantly better in peripheral corneal melts than in central melts (p = 0.004). Conclusion. Lamellar keratoplasty is an effective method of restoring the integrity of the eye ravaged by corneal melting. It is less invasive and consequently safer than penetrating keratoplasty in actively inflamed and unstable eyes. The primary purpose for this surgery is to salvage the integrity of the globe during the acute phase of disease and not so much to achieve visual improvement per se. It allows time for systemic immunosuppression to take effect and for the eye to quiet down before possible future vision-restoring surgery.

Treatment of ocular graft-versus-host disease with topical cyclosporine 0.05%.

Purpose: To evaluate the efficacy of topical cyclosporine-A 0.05% (CsA) in the treatment of dry eye syndrome in ocular graft-versus-host disease after bone marrow transplantation (BMT) of hematopoietic stem cells. Methods: One-hundred five patients were enrolled in a retrospective, comparative, interventional case series. Eighty-one patients received topical CsA starting 1 month before BMT (treatment group), and 24 patients did not receive CsA until at least 6 months after the transplantation (control group). Mean follow-up time was 17.5 ± 11.0 months (range: 6.0-49.0 months). Clinical history, ocular surface disease index questionnaire, slit-lamp examination, lissamine green and fluorescein staining of the ocular surface, tear breakup time, and Schirmer test with topical anesthesia were obtained to create a composite dry eye-grading score. Results: Dry eye symptoms were significantly more severe in the control group at 3 months, 1 year, and 2 years (P < 0.05). There was no correlation with type of stem cell transplant (related vs. unrelated donor), presenting indication for BMT, or concurrent systemic immunosuppressive medications. Conclusions: Pre-BMT initiation of topical CsA may reduce the inflammatory response in the lacrimal glands that may be responsible for the development of post-BMT keratitis sicca.

Hereditary hemorrhagic telangiectasia diagnosed by the ophthalmologist.

Purpose. To show the clinical features of a case of hereditary hemorrhagic telangiectasia in which the diagnosis was prompted by ophthalmologic examination. Methods. A retrospective case review of a 56-year-old East Indian woman whose presentation to the eye clinic with a history of bloody tears and conjunctival vascular malformations prompted a systemic evaluation that resulted in the diagnosis of hereditary hemorrhagic telangiectasia. Results. The diagnosis of hereditary hemorrhagic telangiectasia was eventually confirmed by gastrointestinal endoscopy and otorhinolaryngologic examination. Conclusion. Although hereditary hemorrhagic telangiectasia is typically diagnosed on the basis of gastrointestinal and otorhinolaryngologic history and examination, the ophthalmologic features of this case were striking enough to arouse suspicion of this disease.

Conjunctival mucoepidermoid carcinoma in a young HIV-infected man.

PURPOSE To report a case of conjunctival mucoepidermoid carcinoma occurring in a long-standing pterygium in a 33-year-old Cambodian man infected with the human immunodeficiency virus (HIV). METHODS Review of clinical history and histopathologic findings. RESULTS A pterygium that was present for 8 years suddenly became highly inflamed and underwent rapid growth. After the initial diagnostic conjunctival and corneal biopsy showed mucoepidermoid carcinoma, subsequent additional deep excisions of the adjacent sclera and cornea were necessary to completely excise the tumor. Cytokeratin and mucicarmine stains were used to confirm the pathologic diagnosis of mucoepidermoid carcinoma. CONCLUSIONS Unique features of this case include the extremely young age of the patient (perhaps rendered susceptible by his HIV infection), the tumor masquerading as a pterygium, and the use of a hybrid lamellar and full-thickness corneoscleral resection requiring a complementary graft. Seventeen months after the resection, the patient is free of tumor; this was histopathologically confirmed with multiple random conjunctival biopsies.

Prognosis for penetrating keratoplasty in iridocorneal endothelial syndrome.

BACKGROUND Iridocorneal endothelial syndrome is characterized by the proliferation and spreading of an abnormal corneal endothelial membrane across the iridocorneal angle and iris surface, resulting in iridocorneal adhesions, glaucoma, pupillary distortion, varying degrees of iris atrophy, and occasionally corneal decomposition with edema. These changes may possibly affect the long-term prognosis of penetrating keratoplasty in an adverse fashion. METHODS We reviewed the clinical course of 12 consecutive eyes (12 patients) which underwent penetrating keratoplasty for corneal edema associated with the iridocorneal endothelial syndrome (mean postoperative follow up = 30 months). RESULTS The grafts remained clear in 10 patients (83%) and the visual acuity was 20/40 or better in nine patients (75%). The endothelial cell losses averaged 13% at 6 months and 17% at 1 year after surgery. Simultaneous extracapsular cataract extraction and posterior chamber lens implantation at the time of keratoplasty posed no measurable compromise to the overall postoperative prognosis. Causes of poor visual acuity after surgery included glaucoma and graft failure (immune and nonimmune). CONCLUSIONS The prognosis of penetrating keratoplasty in the iridocorneal endothelial syndrome appears to be very favorable in the majority of eyes.

Acute hydrops with corneal perforation in post-LASIK ectasia

Purpose: To report a case of corneal hydrops with perforation in a patient with ectasia after undergoing laser in situ keratomileusis (LASIK). Methods: An observational study with clinical, optical coherence tomographic, and histopathologic findings. Results: A 41-year-old woman had an acute onset of blurry vision, pain, photophobia, tearing, and foreign body sensation in the right eye 10 years after undergoing unilateral LASIK in Jordan. According to her, the surgeon elected not to operate on the left eye because of a “corneal abnormality.” On slit-lamp examination, a tear in Descemet membrane with a stromal cleft extending to the overlying LASIK flap interface was noted. The flap was partially dehisced by a diffuse channel of aqueous humor draining from the cleft and streaming out the temporal flap edge. When leakage failed to stop after 2 weeks of treatment with a bandage contact lens, the patient underwent penetrating keratoplasty. Histopathological examination of the host button showed a fluid-filled cleft connecting the flap interface. Slit-lamp examination and corneal topography of the contralateral left eye were consistent with keratoconus. Conclusions: Corneal hydrops with perforation in the setting of post-LASIK ectasia is extremely rare and may be associated with flap dehiscence requiring penetrating keratoplasty.

Outcomes of cataract surgery in eyes with previous herpes zoster ophthalmicus

Purpose To report the outcomes of cataract surgery in eyes with previous herpes zoster ophthalmicus (HZO). Setting Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan, USA. Design Retrospective case series. Methods Eyes with a history of HZO that had phacoemulsification and intraocular lens implantation were reviewed. The information analyzed included the ophthalmologic history, visual acuity, preoperative and postoperative adjunct treatments, and complications. Analysis of the mean corrected distance visual acuity (CDVA) at 1 month, 1 year, and the last follow‐up was performed. Results Twenty‐four eyes were evaluated. The mean CDVA improved from 20/112 (0.75 logMAR ± 0.63 [SD]) preoperatively to 20/53 (0.42 ± 0.56 logMAR) 1 month postoperatively (P = .007) and 20/44 (0.34 ± 0.55 logMAR) at 1 year (P = .052) but decreased to 20/71 (0.55 ± 0.72 logMAR) by last follow‐up (P = .605 versus preoperative CDVA). Eleven patients (45.8%) had recurrent keratouveitis after the first episode, 5 before cataract surgery and 6 after cataract surgery. Three had penetrating keratoplasty for worsening corneal opacification. Two patients had tractional retinal detachment from chronic uveitis and required vitrectomy and retinal repair. Conclusions Visual recovery after cataract surgery in HZO might be compromised by chronic factors such as ocular surface disease and keratouveitis. Despite long quiescent waiting periods before surgery and aggressive preoperative and postoperative maintenance therapy, visual improvement might be hindered by the inherent pathology associated with HZO. Nevertheless, with careful patient selection, reasonable visual improvement can be achieved. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.